HomeMy Public PortalAbout9801 RICHMOND WAY_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that i have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76n6420
a certified copy thereof (Sec. 3800, Lab C. 92-GO02PPw6as APPLICATION FOR PERMIT
Policy No.1CA�`3�174_1'I Company C.�A _U rt1!�►
❑ Certified copy is hereby furnished. I SEWER - SEWAGE DISPOSAL
D—Certified copy is filed with the county building inspection ? COUNTY OF LOS ANGELES BUILDING AND SAFETY S
department.
ate 7� Applicant J t j` (r�iaW V FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING '16C) f, 1 jy h Mo \��
COMPENSATION INSURANCE ADDRESS Lo J
F lJ l/ 1\`l+1 1 t r r�!n f YY STATION DEPTH
jhis section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE UPPER
OWER
'ermit is for one hundre.d dollars ($100)or less.)
certlf that in the performance of the work for which this NEAREST �t TYPE OF CONNECTION LENGTH FR
i Y P CROSS ST. � � U � Y. CURB P1. M.l.TO P.L
permit is issued, 1 shall not employ any person in any manner �� / t
so as to become subject to the Workers' Compensation Laws. Y�l e5+c o !�.®l�o$ P.C.NO.
OWNER �" �y CO.IMP.NO. JOB NO.
MAIL �a n)'G, 1y TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS vt1 Pyr
NOTICE TO APPLICANT: If, after making this Certificate Of _TP 1 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO: DATE
9 CITY { TEL.NO.
Exemption, you should become subject to the Workers' I
GAL
Compensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY-OR ST.WIDENING
comply with such provisions or this permit shall be deemed
5 revoked. TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
F LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter f
9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES
ness and Professions Code, and my license is in full force and
effect. .I, RACTOR %'� .� � E� 'p CONNECTION CHARGE FEELicense Number fZ 4 U� L'Ic.Class ' ° ESS JAP5` C i--e REIMBURSEMENT FF.E
-r , DISTRICT NO. GROUP MAP PROCESSED BY
ContractorIm c��4f' late F d 1 n�Y� 1 I TEL.NO . .`. '� BK PGI am exempt under Sec. 4�V0 _of the L.A.Co. SE NO. �L -A 7-U5 CLAss �1
r c
Plumbing Code and!or Sec" of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO >7 (: I PATE VAL ATION
B. R P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL r
- PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY ! -
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER `
OVERFLOW SEEPAGE PIT,DRAINFIELD G
I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM ,
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business a S
and Professions Code). OWNER'S Permit S ( C
4 i ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE _ > )' ,' � 3,1
licensed contractors to construct the7
S
j
roect (Section 044,
P ( 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ++
3 CONSTRUCTION LENDING AGENCY
SIGNED THIS DAY OF 19_
I hereby affirm that there is a construction lending agency , y
for the performance of the work for which this permit is OWNER
OWNERS AGENT k
sued (Sec. 3097 Civ. C. . _
p) f ADDRESS
Lender's Name_
Lender's Address
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon It , above-mentioned prqpsty for inspection purposes.
'Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE